DETAILED CLINICAL MOTIVATION REQUIRED WITH STENT TYPES AND DATES AND HISTORY OF THERAPY

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

ANTICOAGULANT

WARFARIN 5MG

CIPLA-WARFARIN 5MG

712390

ASPEN-WARFARIN 5MG

778362

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITORS

ASPIRIN 300MG

BAYER ASPIRIN 300MG

706930

BAYER ASPIRIN CARDIO 100MG

862304

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITORS

ASPIRIN 100MG

MYOPRIN 100MG

845590

BAYER ASPIRIN CARDIO 100MG

862304

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITORS

ASPIRIN 81MG

ECOTRIN 81MG

823481

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITOR

DIPYRIDAMOLE 100MG

PLATO 100MG

720526

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITOR

DIPYRIDAMOLE 25MG

PLATO 25MG

755656

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PLATELET AGGREGATION INHIBITOR

DIPYRIDAMOLE ER 200MG

PERSANTIN 200MG RETARD CAP

851108

THROMBOANGITIS OBLITERANS (BUERGER)

I73.1

PERIPHERAL VASODILATORS

PENTOXIFYLLINE 400MG

ASPEN PENTOXIFYLLINE SR 400MG

703629

DYNA-PENTIFYLLINE SR 400MG

709077

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

PREDNISOLONE 5MG

CAPSOID 5MG TAB

814407

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

PREDNISONE 5MG

TROLIC 5MG TAB

818267

PANAFCORT 5MG TAB

752304

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

PREDNISONE 50MG

METICORTEN 50MG TAB

742759

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

METHYLPREDNISOLONE 4MG

MEDROL 4MG TAB

741116

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

METHYLPREDNISOLONE 16MG

MEDROL 16MG TAB

741124

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

BETAMETHASONE 0.5MG

BETANOID 0.5MG TAB

826928

THROMBOCYTOPAENIA

D69.3

CORTICOSTEROIDS

BETAMETHASONE SYRUP 06MG/5ML

BETANOID 0.6MG/5ML

826936

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

CIMETIDINE 200MG

CIMLOK 200MG

854247

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

CIMETIDINE 200MG

BIO-CIMETIDINE 200MG

886978

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

CIMETIDINE 400MG

CIMLOK 400MG

854255

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

CIMETIDINE 400MG

BIO-CIMETIDINE 400MG

887003

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

RANITIDINE HCI 150MG

HISTAK 150MG

841765

ULTAK 150MG

867934

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

HISTAMINE-2 RECEPTOR ANTAGONISTS

RANITIDINE HCI 300MG

HISTAK 300MG

841773

ULTAK 300MG

867942

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

LANSOPRAZOLE 15MG

LANCAP 15MG

708052

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

LANSOPRAZOLE 30MG

LANCAP 30MG

708053

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

OMEPRAZOLE 10MG

OMEZ 10MG

703461

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

OMEPRAZOLE 20MG

OMEZ 20MG

703459

NOZER 20MG

704629

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

PANTOPRAZOLE 20MG

PANTOCID 20MG

715610

MYLAN PANTOPRAZOLE 20MG

717420

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

ZOLLINGER - ELLISON SYNDROME

E16.4

PROTON PUMP INHIBITORS

PANTOPRAZOLE 40MG

PANTOCID 40MG

708031

MYLAN PANTOPRAZOLE 40MG

717421

GASTROSCOPY RESULTS REQUIRED - INCLUDE LOS ANGELES GRADING.

DISCLAIMER

Please note this formulary is reviewed on a regular basis by the PHA clinical committee to ensure adherence to the most current and approved clinical guidelines for the treatment of the listed conditions. PHA and the clinical committee reserve the to amend the medicine list via addition, removal or replacement of listed medicines on the formulary if and at such times, updated clinical information becomes available regards treatment of a condition, safety, and efficacy of listed products and/ or improved therapeutic outcomes are made available. This formulary is intended to be used as a guide to the approved treatment of the condition but in no way or manner is intended to substitute the professional knowledge of the individual prescribing or dispensing the said medication. PHA shall not under any circumstances be liable for any side-effects or other consequential or incidental harm of any kind or description whatsoever arising from the use of, or failure to use, any medicine on the strength of information contained in this formulary.

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